Form C-4 "Application for Certification of Quality and Condition Applicant's Declaration of Origin" - Hawaii

What Is Form C-4?

This is a legal form that was released by the Hawaii Department of Agriculture - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the Hawaii Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form C-4 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Agriculture.

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Download Form C-4 "Application for Certification of Quality and Condition Applicant's Declaration of Origin" - Hawaii

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Form C-4 (rev. 10/14)
State of Hawaii
APPLICATION FOR CERTIFICATION OF
Department of Agriculture
QUALITY AND CONDITION
APPLICANT’S DECLARATION OF ORIGIN
Quality Assurance Division
Commodities Branch
GREEN COFFEE BEANS
Part I must be completely filled in and signed. Response is required to obtain certification service.
PART I I understand that the Hawaii Department of Agriculture uses the following information in its certification of quality,
and condition of green, natural and mixed natural coffee beans. I agree and understand that utilizing a certification that is
based on any misstatements I provide herein may constitute a violation of Chapter 147, Hawaii Revised Statutes (HRS),
or Title 4, Subtitle 7, Chapter 143, Hawaii Administrative Rules (HAR), and may result in the penalties set forth in Section
147-2, HRS and/or Section 4-143-8, HAR.
I certify that the following lot/s of green, natural or mixed natural coffee beans offered for certification were produced in the
geographic region of ___________________, as defined in Section 4-143, HAR on the island of ________________, tax
may key nos. ______________________________________________________.
GRADE
NO. OF SACKS
NET WEIGHT (LBS.)
Applicant/Address:
Remarks:
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
Signature Coffee Owner/Representative
Date
Applicant’s Phone No.
_________________________________________________________
_______________________________________________________
Print Name
Print Company Name
Part II I understand that the Hawaii Department of Agriculture uses the following information in its certification of quality
and condition of green coffee beans. I agree and understand that utilizing a certification that is based on any
misstatements I provide herein may constitute a violation of Chapter 147, Hawaii Revised Statutes (HRS), or Title 4,
Subtitle 7, Chapter 143, Hawaii Administrative Rules (HAR), and may result in the penalties set forth in section 147-2,
HRS and/or section 4-143-8, HAR.
I certify that the ___________pounds of cherry/parchment coffee offered for milling to parchment/green beans were
circle one
circle one
produced in the geographic region of _____________________, as defined in Section 4-143-3, Hawaii Administrative
Rules, on the island of _____________________, tax map key nos.___________________________________________
___________________________________________
Signature Coffee Owner/Representative
Date
__________________________________________________________
_______________________________________________________
Print Name
Print Title
Print Company Name
Form C-4 (rev. 10/14)
State of Hawaii
APPLICATION FOR CERTIFICATION OF
Department of Agriculture
QUALITY AND CONDITION
APPLICANT’S DECLARATION OF ORIGIN
Quality Assurance Division
Commodities Branch
GREEN COFFEE BEANS
Part I must be completely filled in and signed. Response is required to obtain certification service.
PART I I understand that the Hawaii Department of Agriculture uses the following information in its certification of quality,
and condition of green, natural and mixed natural coffee beans. I agree and understand that utilizing a certification that is
based on any misstatements I provide herein may constitute a violation of Chapter 147, Hawaii Revised Statutes (HRS),
or Title 4, Subtitle 7, Chapter 143, Hawaii Administrative Rules (HAR), and may result in the penalties set forth in Section
147-2, HRS and/or Section 4-143-8, HAR.
I certify that the following lot/s of green, natural or mixed natural coffee beans offered for certification were produced in the
geographic region of ___________________, as defined in Section 4-143, HAR on the island of ________________, tax
may key nos. ______________________________________________________.
GRADE
NO. OF SACKS
NET WEIGHT (LBS.)
Applicant/Address:
Remarks:
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
Signature Coffee Owner/Representative
Date
Applicant’s Phone No.
_________________________________________________________
_______________________________________________________
Print Name
Print Company Name
Part II I understand that the Hawaii Department of Agriculture uses the following information in its certification of quality
and condition of green coffee beans. I agree and understand that utilizing a certification that is based on any
misstatements I provide herein may constitute a violation of Chapter 147, Hawaii Revised Statutes (HRS), or Title 4,
Subtitle 7, Chapter 143, Hawaii Administrative Rules (HAR), and may result in the penalties set forth in section 147-2,
HRS and/or section 4-143-8, HAR.
I certify that the ___________pounds of cherry/parchment coffee offered for milling to parchment/green beans were
circle one
circle one
produced in the geographic region of _____________________, as defined in Section 4-143-3, Hawaii Administrative
Rules, on the island of _____________________, tax map key nos.___________________________________________
___________________________________________
Signature Coffee Owner/Representative
Date
__________________________________________________________
_______________________________________________________
Print Name
Print Title
Print Company Name